Systems and Methods for Benefit Plan Management in Accordance with Captured User Intent

Abstract

A system for providing end-to-end traceable benefit plans includes an intake engine configured to generate, from input source data, a plurality of benefit plan components having one or more cross-dependencies with respect to each other, wherein the benefit plan components include: data structures reflecting benefit plan aspects and associated rules for implementation with respect to the benefit plan. The system includes an intake dashboard configured to intake the input source data provided by a user via the intake dashboard, the input source data capturing user intent with respect to benefit plan design and / or configuration. The system includes an extractor configured to extract the input source data from source systems, and an assembly module configured to assemble a benefit plan file from the benefit plan components, the benefit plan file associating benefit components with and across workflows and systems. The system includes a claims processing IT environment configured to load the benefit plan file, and to process claims in accordance with the benefit plan file.

Description

[0001]This application claims the benefit of U.S. Provisional Application No. 62 / 794,345, filed on Jan. 18, 2019, the entire contents of which are hereby incorporated by reference.BACKGROUND ART[0002]A typical benefit management enterprise manages hundreds if not thousands of individual benefit plans, including benefit plans for medical benefits and / or pharmaceutical benefits. These managed benefit plans typically include thousands of groups, millions of members, and hundreds of millions of claims to be processed.[0003]The management of benefit plans also typically involves managing a combination of various disparate components, including data structures for the various aspects of the benefit plans, such as, for example, plan architecture, copays, formularies, networks, accumulators, etc. The intricate interdependencies between these components is usually not documented nor well understood due to the complex nature of the integrations among components.[0004]In addition, in managing ...

AI Technical Summary

Benefits of technology

This patent describes a new system for managing benefits for employees that improves traditional systems by providing end-to-end traceability. This means that the system can identify and track all the components and dependencies in the benefits plan, reducing the number of components that need to be maintained and improving efficiency. The system also minimizes errors and impact during auditing and helps adjust the benefits plan based on data and analysis. Overall, this system makes benefits management more effective and cost-efficient.

Problems solved by technology

The intricate interdependencies between these components is usually not documented nor well understood due to the complex nature of the integrations among components.

The use of such systems and techniques results in multiple challenges.

These challenges include: higher costs of managing benefits, reliance on error prone manual work arounds, and a general lack of tracking and maintaining audit friendly information (which may be required for meeting compliance goals).

As a consequence, data is often duplicated, and opportunities for the reuse of the benefits components are limited.

An additional consequence of traditional benefit management occurs when errors in adjudicating benefits claims within a claims processing IT environment manifest.

Because of the lack of end-to-end traceability at each step of the adjudication processes, it is prohibitively difficult to determine the root cause of the error, as well as its potential effect on the adjudication of other claims.

Moreover, if a root cause is eventually identified, it may not be readily foreseeable how changes to the benefit plan components addressing the root cause of the error might affect the adjudication of the changed benefit plan in other respects.

Similar consequences occur when new benefit plans, or changes to existing benefit plans, do not accurately reflect client intent.

Because of the large number of components and general lack of end-to-end traceability, it is difficult to determine, once the benefit plan is implemented, the root cause of an inaccuracy, which makes it difficult to make the necessary corrections to align the benefit plan with the client intent.

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